Family planning: Where do we stand today?

It is estimated that family planning could prevent one in every three maternal deaths and one in 11 child deaths by allowing women to delay motherhood and space their births, avoid unplanned pregnancies and therefore abortion, and stop childbearing once they have reached their planned family size (Lancet, 2006). Approximately 200 million married women who want to stop having children or postpone their next pregnancy do not have access to any method of contraception and family planning services because of logistical and financial barriers. In addition, there are a further 12–15 million unmarried women who want to avoid pregnancy and have no access to clinics or family planning services due to the associated cultural stigma of the region (WHO Media Centre, 2011). Despite a 28 percent increment in contraception uses globally in the last 45 years, data shows a stark disparity in the range of percentage of women taking recourse to contraceptive methods in Asia.

The South Asian region still counts for the highest burden of maternal deaths despite its efforts to increase access to modern family planning to reduce total fertility rates (TFR). In India, Nepal, Pakistan and Bangladesh in particular, the differences in fertility and use of contraception across socioeconomic groups are striking. In India, the fertility rate among the wealthiest part of the population is only 1.8, while it remains 3.9 among the poorest. In Nepal, educated women have on average 1.9 children while the least educated have an average of 3.7. In Pakistan, contraceptive prevalence is 32 percent among wealthier couples and yet only 12 percent among poor couples. In Bangladesh, the urban total fertility rate is 2.0 and that of the rural areas is 2.4 (BDHS, 2014).

Rapid population growth in resource-constrained countries impairs the ability to develop quality life and livelihood; family planning contributes to fertility decline. Since the 1960s, contraceptive use introduced as a means of family planning in Bangladesh and fertility has fallen substantially to date. The decline has been uneven as the performance of family planning programmes across the country varied widely. So what can be done to increase consistent use of contraceptive across the country and reduce fertility?

Experts suggest three major factors that could aid population and fertility control: (i) uninterrupted supply of contraceptive commodities; (ii) strengthening and extending a structured network through the existing health and family system (government organisations, NGOs, private) to enhance services; and (iii) periodically examining the policy implications of differing patterns of fertility and population growth for national development and individual well-being.

Bangladesh now has an estimated population of 168 million. In 1971, a nationwide survey confirmed that there were 71 million people back then. In 1980, the population grew to 90.4 million and similar rises have been recorded on a decade-by-decade basis ever since. The population of Bangladesh is equivalent to 2.18 percent of the global population (seventh largest in the world). The country has a population density of 1,115.62 people per square kilometre (World Population Review).

World Population Day today calls for global attention to the unfinished business of the 1994 International Conference on Population and Development. Twenty-five years have passed since that landmark conference, where 179 governments recognised that reproductive health and gender equality is essential for achieving sustainable development.

In Bangladesh, family planning programmes are carried out by government agencies, NGOs and limited private services which are coordinated by the Directorate General of Family Planning. At the London Summit on Family Planning (FP2020) in July 2012, Bangladesh committed to the overall goal of ensuring quality and equitable family planning services for all eligible couples by improving accessibility to family planning services, particularly for the poor. Specific targets have been set for reducing total fertility rate, increasing contraceptive prevalence rate and method-specific coverage, while reducing the rate of discontinuation and overall unmet needs for implementing family planning programmes. Family planning remains one of the top priorities in the 4th Health Sector Programme 2017-2021, as a path toward achieving the Sustainable Development Goals. Meanwhile, Bangladesh has had commendable achievements during the last decade in reducing population growth and improving maternal and child health. The reduction in the total fertility rate from 6.3 births per woman in 1975 to 3.4 in 1994 and to 2.3 in 2011 is very encouraging, but since 2011, the total fertility rate has remained stagnant at 2.3 births per woman (BDHS, 2014). Besides, 12 percent of married women in Bangladesh are unable to receive necessary family planning services. Such unfulfilled needs vary according to geographical location. The problem is most acute in Sylhet (BDHS, 2014).

One of the major concerns for family planning programmes is the rate at which users discontinue use of contraception. It has been found that 30 percent of contraceptive users stop using such methods within 12 months of starting. Discontinuation rates are much higher for temporary methods like condoms (40 percent) and the pill (34 percent), than for longer term methods like implants (seven percent). The BDHS 2014 revealed that 31 percent of women aged between 15 and 19 have begun childbearing; about one in four teenagers have given birth and another six percent are pregnant with their first child. Childbearing among teenagers is more common in rural than in urban areas (32 live births versus 27 per 1,000 women, according to BDHS 2014). A large cohort of young Bangladeshis will reach reproductive age in the coming decades, so the adolescent fertility issue must be addressed with the highest priority. The adolescent (15-19) fertility rate in Bangladesh is 113 per 1,000 women (BDHS, 2014) and has not decreased significantly for decades. Adolescent fertility remains a major social and health concern. Despite rapid improvement in female education, women's mean age at marriage has hardly changed.

The achievements in family planning in Bangladesh have so far significantly increased access for poor people in urban slums and remote rural areas. Efforts that emphasise on improving choice—availability of Long Acting and Permanent Methods (LaPMs), including those for men, and post-partum and post-abortion services—also have momentum today. Certain family planning services like counselling needs have to be established in commonly hard-to-reach areas such as char, hilly areas, haor, and minority communities, along with residential workplaces. The "floating boat hospital" containing health and family planning services through satellite clinics seems like a great solution to reach char people even during floods. New couple counselling, doorstep package services for faith-based communities, adolescent counselling centre at Upazila Health Complexes (UHCs), and segmented service units for specific target groups can be considered to increase outreach. The EPI centre, community clinics, birthing centres/UHCs, and private clinics shouldn't have a shortage of required supplies and trained midwives. The health system may revisit existing involvement by multi-ministries/sectors and extend its network based on recent experiences so as to engage other sectors and stakeholders including education, women and children affairs, hill tracts, local government and cooperatives, the youth, religious affairs, NGOs, and the private sectors. The collective efforts to provide access to quality, affordable reproductive health care and reduce adolescent fertility rates overall promote optimal birth spacing and establish the importance of family planning, which in turn contributes towards individual happiness and also further national development.

Kazi Amdadul Hoque is a humanitarian and public health professional. Email: hoqueka@gmail.com

Follow The Daily Star Opinion on Facebook for the latest opinions, commentaries and analyses by experts and professionals.

To contribute your article or letter to The Daily Star Opinion, see our guidelines for submission.